Communicating a Plan for Involuntary Psychiatric Admission: A Standardized Patient Workshop Intervention for General Psychiatry Residents

Introduction One important and often difficult act of communication common in psychiatry is communication regarding the need for involuntarily commitment for psychiatric treatment. Thus, we designed an educational workshop for psychiatry residents on how to communicate the plan for involuntarily commitment to a psychiatric hospital. Methods Using faculty expertise, we created a protocol to guide trainees on how to structure conversations around involuntary commitment. Residents first attended a didactic on the protocol, followed by a 1-hour workshop with standardized patients (SPs) 1 week later. The workshop consisted of three 14-minute simulated scenarios with the SP with debriefing. Trainees filled out pre- and postworkshop surveys. Results Fifteen and 12 residents completed the pre- and postworkshop surveys, respectively. Residents' perceived comfort level in their ability to deliver involuntary commitment news significantly improved after the workshop when compared to before (3.0 vs. 3.7 for pre- and postworkshop surveys, respectively). Residents trended toward intending to make more changes to their approach after the workshop when compared to before (2.2 vs. 2.6, respectively). Feedback on the didactic and workshop were largely positive. Discussion To our knowledge, our intervention is the first designed specifically to teach psychiatry residents how to communicate to patients that they are being involuntarily committed to emergent psychiatric treatment. This educational model has potential for improving resident skills and confidence in having difficult conversations around involuntary commitment.


Introduction
Delivering difficult news can be distressing to physicians and patients and may result in either strengthening or weakening commitment to psychiatric treatment.Involuntary commitment is the process by which a patient is admitted to a psychiatric facility due to concerns for immediate substantial likelihood of serious harm as a result of a mental illness or emotional disturbance, either against a patient's expressed wish or when the patient is deemed unable to make the decision for admission him-or herself.Maintenance of a therapeutic alliance is paramount to psychiatric treatment, and informing a patient that some individual rights are being restricted can feel challenging and distressing.It can be particularly difficult if the patient is suffering from severe mental illness impacting insight, judgment, and emotion regulation.Furthermore, such a decision is fraught with ethical, personal, cultural, and moral conflicts, 16 and thus, psychiatrists may feel conflicted in both making and communicating the decision.To our knowledge, there is little, if any, literature on communication skills training for sharing news with a patient that they are being involuntarily committed into a psychiatric facility, including in MedEdPORTAL.While there is formal education and training regarding when involuntary commitment should be considered or the ethical considerations in involuntary commitment, it is our experience that training on how to effectively communicate the need for involuntary commitment is inconsistent, mostly occurring through unstructured observed interactions in acute medical or psychiatric settings, as is the case with our institution.
To assess the scope of this learning gap in psychiatric training, we designed and distributed a needs assessment survey to general psychiatry residents at Vanderbilt University Medical Center in July and August 2021 (Appendix A).Out of 23 responses, all residents except two (91%) had never received formal teaching on how to tell patients they were being involuntarily committed, clearly indicating the lack of existing instruction on such conversations.Three-fourths of residents (n = 17) rated their comfort in their ability to tell a patient that they were being involuntarily committed as 3 or less out of 5 (1 = not at all comfortable, 5 = very comfortable).Nine residents (39%) indicated that they had avoided telling a patient that they were being involuntarily committed due to fear of how they would react (Table ).Residents of all years feared that discussions about involuntary commitment would lead to patient violence or agitation (60%-69%) and disliked giving disappointing news (44%-58%; Figure 1).Three open-ended responses were received regarding what residents felt uncomfortable about: "What to do when patients become agitated"; "In wrong context, strapped for time, I deliver the news, potentiate agitation, then have to leave and my colleagues have to deal with the consequences"; and "My main concern is that many patients are not in the current state to be accepting of this information and the issues with agitation or violence can be difficult to manage for all team members."Overall, the survey indicated a discomfort across all years of training with sharing involuntary commitment news with patients related to fear of patient agitation.
While patient agitation cannot be prevented, increased preparation can help improve confidence and reduce distress around these conversations.Thus, we designed a workshop for psychiatry residents on how to communicate to a patient the plan for involuntary commitment to a psychiatric hospital.We created a protocol to guide residents on the structure of such a conversation based on clinical experience and review of effective communication practices.Residents first attended a didactic session on the protocol, followed by a 1-hour standardized patient (SP) workshop 1 week later.][19] Recognizing that there are various acceptable ways of effective communication, our intention was to provide a suggested structure for the conversation to build resident confidence and decrease discomfort, as well as an opportunity to put it into practice.Emphasis for our activity was placed on teaching over assessment; the latter was intended to be low stakes and formative.

Methods
The involuntary commitment workshop was included as a voluntary addition to the curriculum of the general psychiatry residency program at Vanderbilt University Medical Center in 2021.Target learners included all general psychiatry residents across all 4 years of the program, for a maximum of 33 learners.Prerequisite knowledge included knowing the involuntary commitment criteria of the state of Tennessee, as well as conducting a basic psychiatric interview.
Protocol Design Unstructured interviews were held with two faculty members from the emergency psychiatry and consultation-liaison psychiatry departments.Data were consolidated into a draft protocol, which was then circulated to the faculty who had originally been interviewed, as well as two additional faculty members, for feedback and refining.Edits received after the initial draft protocol were minimal, suggesting a high level of agreement with the protocol steps among all faculty members.The protocol consisted of five steps, plus a preprotocol step 0: (0) initial intake; (1) preparation and safety; (2) summarize concerns and state rationale; (3) be transparent and clearly state involuntary commitment decision; (4) listen, emphasize, and reemphasize the decision; and (5) postconversation communication.The acronym P.S.TLC was used for ease of remembering the protocol steps.
For details of the protocol, see Appendix B.

Implementation
One week before the workshop (October 2021), a 1-hour didactic was held as part of the regular weekly resident education schedule.Results of the needs assessment survey were shared, residents were taught the protocol, and two expert discussants shared their experience and answered questions.Residents were emailed a copy of the presentation as well as the scenario prompts to prepare if desired.
Residents were assigned to attend 1 of 2 workshop days, one for PGY 1 and PGY 4 residents and the other for PGY 2 and PGY 3 residents.A link to the preworkshop survey was emailed the day before each workshop, and paper copies were also brought to the workshop.The workshop took place in a large conference room and one smaller classroom-sized overflow room, with chairs arranged in small groups spread out among the space.
No additional equipment was required.
At the workshop, residents were divided into groups of two to three per SP.An upper-level resident (i.e., PGY 3 or PGY 4) was assigned to each group where possible.The first 5 minutes were used to fill out the preworkshop survey for those who had not done so online.The remaining time was broken into three 14-minute scenarios, with 2 minutes given to read the scenario, 8 minutes to conduct the encounter with the SP, and 4 minutes for feedback.One minute was allotted for transition between rotations.All residents had the opportunity to perform an encounter.Remaining residents in each encounter observed alongside and used a protocol feedback checklist to deliver feedback along with the SP after the scenario.Two facilitators (Kimberly Hsiung, Daniel Daunis) were present to keep track of time, help manage the rotation of groups during transitions, and guide feedback discussions if needed.After all three scenarios, residents filled out the postworkshop survey.A link to the postworkshop survey was also emailed to all residents who attended.The vast majority of surveys were filled out at the workshop.
The first scenario featured a 50-year-old female with a history of bipolar I disorder brought in by police due to bizarre behavior, with concern for acute mania.The second scenario depicted a 60-year-old female with a past medical history of multiple strokes, brought in by her husband for worsening delusions that the CIA and FBI were conspiring against her.The third scenario featured a 20-year-old male brought in after overdosing on diphenhydramine tablets as a suicide attempt.

Assessment
Postdidactic feedback survey: Since the didactic was incorporated into the regular weekly resident educational schedule, a standard online feedback survey that typically followed regular educational didactics was used.The survey consisted of two open-ended questions, one asking for feedback regarding the quality of written handouts, and the second asking for feedback regarding the presentation.
Preworkshop survey: Outside of demographic information, the preworkshop survey consisted of two questions: "How comfortable are you with your ability to deliver news to a patient that they are being involuntarily committed to [the psychiatric hospital]?"and "After learning the protocol steps discussed in last week's didactic, how much do you intend to change your approach to involuntary commitment conversations going forward?" Response options were 5-point Likert scales (Appendix E).
Protocol feedback checklist: To facilitate the peer feedback session, participants were given a feedback checklist with the steps of the P.S.TLC protocol and space for notes as a structured guide.There was no reliability testing to assess the feedback given on the protocol steps.This was because the emphasis of the feedback session was more on having learners of varying levels share experiences and ideas and less on strictly following the steps of the protocol, which had not been rigorously validated (Appendix F).
Postworkshop survey: The postworkshop survey again asked for comfort level and intent to change approach with the same 5-point Likert-scale response options.Including these two questions in both pre-and postworkshop surveys allowed us to measure the extent to which we met Educational Objectives 1 and 2. The survey also provided a space for open-ended and rated feedback on various aspects of the workshop.Finally, participants were asked to share a learning point from the workshop experience (Appendix G).

Statistics
All data from surveys were collected and organized using Vanderbilt REDCap. 20To assess change in comfort level and intent to change approach pre-and postworkshop, simple summary statistics were used.Data were not paired.

Pre-Versus Postworkshop Survey Comparisons
Residents' perceived comfort level in their ability to deliver involuntary commitment news improved after the workshop when compared to before it (3.0 vs. 3.7 for pre-and postworkshop surveys, respectively).There was a trend toward residents intending to make more changes to their approach after the workshop when compared to before (2.2 vs. 2.6 for pre-and postworkshop surveys, respectively).Figure 2 shows response breakdowns.
Didactic and Workshop Feedback Feedback on the didactic was overall positive.Many residents commented that they found the didactic helpful and an important topic to review.Some comments expressed appreciation for seeing what other residents struggled with and the progression of these struggles over time.
Feedback on the workshop was overall also positive, with 11 out of 12 residents rating the workshop scenarios as excellent and 10 out of 11 residents believing that the training should be repeated next year in some fashion.Residents shared several learning points, including empathic listening, the importance of preparation, and knowing when to terminate the conversation (Figure 3).

Discussion
Informing patients that they are being involuntarily committed to emergent psychiatric treatment can be uncomfortable.Our needs assessment survey results revealed that among general psychiatry residents, there was a persistent fear of patient agitation precipitated by these conversations.To our knowledge, our intervention is the first protocol and training designed specifically to teach psychiatry residents how to communicate to patients that they are being involuntarily committed to emergent psychiatric treatment.
Our results show that after our workshop intervention, residents felt more comfortable in delivering involuntary commitment news than before.Results also reveal a trend toward residents intending to make more changes to their approach after the intervention than before, showing that the intervention may have inspired a change in practice.Our qualitative feedback indicates that our intervention, particularly its use of SPs, was generally well received by residents, with an overwhelming majority hoping to have this workshop again next year.
Reflecting on the overall execution of our work, we find there are several valuable takeaways.Distributing the needs assessment survey to the residents and sharing its results with them played

DidacƟc Feedback
"Very well done and a needed addiƟon to our didacƟcs.""I think it's a helpful thing to review and definitely will help guide how I navigate these situaƟons in the future.""I really appreciated the data presentaƟon from the survey.The Ɵps given were easy to remember and implement.""Really enjoyed this presentaƟon as a scaffolding for difficult conversaƟons.""Well organized and very well supported by excellent discussants; overall very helpful.""The presentaƟon was very helpful.I especially appreciated seeing the data, which helped me to understand which parts of involuntary commitment may become easier and which won't "I think discussing the cases generally and with different classes of residents was the best part of the seminar.""Prep, consistency, and use protocol.""EmpatheƟc statements go a long way.""Finding a good stopping point: avoiding going in circles.Usually aŌer you've listened/empathized then restated.""EmpatheƟc listening and being clear with decision.""Knowing when to terminate an unproducƟve conversaƟon aŌer involuntary commitment.""I will try to focus on eliciƟng the paƟent's concerns about being in the hospital and addressing those.""Have a plan!" "Empathy and openness are important."a vital role in revealing the shared discomfort in communicating involuntary commitment decisions, as well as inspiring buy-in for the need for specific training.Residents expressed a sense of relatedness in seeing the data reflecting the experience of their peers and shared that having a guide for such conversations was an important part of training.
The didactic was crucial in providing residents a tangible framework for the conversation with introducing the P.S.TLC protocol and in preparing them for the hands-on workshop to follow.Our time was restricted to an hour in order to feasibly integrate the workshop into our institution's regular educational schedule; additional time would have allowed an opportunity for more interactive learning, such as simple role-plays to practice each step of the protocol, and/or space for residents to share experiences, concerns, advice, and support with one another, which could be a powerful part of learning for a conversation that can be uncomfortable and distressing.
Regarding the workshop, residents specifically appreciated the use of SPs in making the scenarios appear as realistic as possible.Having a mixture of residents in different stages of training in the same group was also seen as a valuable learning opportunity, with the more experienced residents serving as an example to the more junior ones.Attendance was small overall, which limited interpretation of the impact of our findings, although it did favor the PGY 1 residents, who appear to have benefited most from this intervention.We also later discovered that PGY 3 residents had difficulty getting to the workshop in person due to needing travel time between clinics, which explained their limited attendance.Based on this feedback, we implemented a second iteration the following year targeted to the PGY 1 class only.A PGY 4 chief resident joined each small group to perform an encounter as an example for the PGY 1 residents and also to gain supervisory experience for themselves by facilitating the feedback discussion.Attendance was promoted in this second iteration by making the workshop mandatory.
The timing of the workshop in the academic year was important; being a few months into the year, the PGY 1s had experienced the discomfort of involuntary commitment conversations by this point and could see the clinical relevance of the workshop.Our intervention was minimally resource intensive which would make it feasible to reproduce-it was easily introduced into the regular education schedule, and the SPs and services were all free of charge.
Our work has several limitations.First, we recognize the lack of a formal, rigorous method to design and validate the P.S.TLC protocol.Our methods were largely empirical, with input received from only a select population in a single academic institution.Methods of handling agitation concerns may vary depending on local/regional resources, systems of care, and culture.Nevertheless, themes of conveying transparency, genuine concern, and empathic listening are universal in effective communication and likely would vary little if the protocol is developed in a different setting.Finally, our evaluation approach only measures outcomes immediately following our intervention.An outcome measure that may have greater validity in measuring direct impact to patient care would be to assess resident comfort after encountering real-life patient scenarios.
Learner feedback indicated a high interest in having this intervention again in the future.In light of this feedback, there are several potential directions for improvement.The didactic session can be expanded to include more in-session practice role-plays, as well as time to explore resident concerns and fears.Also, an important aspect of communicating involuntary commitment is that the provider must be convinced of the patient's need for involuntary commitment and clear on the reasons why; additional educational time preceding this intervention could focus on learning when involuntary commitment is an appropriate decision to make.Such a decision includes ethical and legal considerations, which may also be an important addition to a future iteration of this intervention.Additionally, our assessments did not formally include objective measures of residency competency.Knowing how fluid conversation can be, our intention with this intervention was not to standardize communication, especially after such a short workshop intervention, but to start with targeting resident discomfort by providing a communication framework and practicing in the face of agitated patients.Future direction may include having more objective assessment, for example, assessing learners on completion of the protocol steps.Finally, having a repeat survey to reassess resident comfort level several months following the intervention would help to determine the extent of its lasting impact.
In summary, we identified that psychiatry residents in our training institution found involuntary commitment conversations challenging due to fear of patient agitation.While preventing agitation may not be completely avoidable, explicit training in this area improves resident preparation and confidence in these circumstances.Our intervention was effective in increasing resident comfort around involuntary commitment discussions and in inspiring change to residents' current approach.As a proof-of-concept, integrating the intervention into regular residency educational curricula was shown to be highly feasible.Having this intervention reproduced in other residency programs would offer more insight into its validity in improving resident comfort surrounding delivering involuntary commitment news.

Figure 1 .
Figure 1.Distribution of needs assessment survey results by year.Participants rated each statement on a scale from 0 to 100, with 100 meaning absolutely true.In the boxes, x = mean, and the open circle (•) = data point.

Figure 2 .
Figure 2. Pre-and postworkshop survey results on intent to change approach and comfort with delivering involuntary commitment news.

Table .
Population Demographics

is your learning point/takeaway from this workshop experience?
." "Excellent presentaƟon and liked seeing what we struggle with and where growth might happen naturally in our training (though we could lessen the Ɵme spent floundering) and where we need to sƟmulate growth otherwise we leave without having developed comfort with a parƟcular process of the talking about involuntary commitment."